565802133-7-9-2024-29-AS-ECOZ-D6ZU9Y-20240709152354

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 565802133
Report Date: 07/09/2024
Date Signed: 07/09/2024 03:24:28 PM

Document Has Been Signed on 07/09/2024 03:24 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS N.ASC, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME:	ROSE GARDEN MANOR IV		FACILITY NUMBER:	565802133
ADMINISTRATOR:	SORATORIO, AMALIA		FACILITY TYPE:	740
ADDRESS:	745 BERKSHIRE PLACE		TELEPHONE:	(805) 246-5148
CITY:	OXNARD	STATE: CA	ZIP CODE:	93033
CAPACITY:	6	CENSUS: 6	DATE:	07/09/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	09:00 AM
MET WITH:	Amalia Soratorio		TIME COMPLETED:	03:30 PM

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Licensing Program Analyst (LPA) Esther Cortez arrived at the facility unannounced to conduct a required annual visit at 09:00AM. The LPA met with Licensee Amalia Soratorio and was explained the reason for the visit. There were no clients or any other staff when the LPA arrived. The home is vendored by Tri-Counties Regional Center as a level 4-E home.

RECORD REVIEW: Beginning at 09:15AM, the LPA conducted a record review. Records were reviewed for documents including, but not limited to: health screening, TB test, staff training records, fingerprint clearance, resident physician's report, needs and service appraisal, personal rights, and resident cash resources. Five (5) resident records reviewed were complete and contained all required documents. 5 (five) staff files reviewed were complete. The LPA reviewed P&I records for all residents. Cash resources were separate and intact, and not be commingled with facility funds or petty cash.

The LPA left the facility at 11:45 AM and returned at 1:15 PM. When the LPA arrived there were six (6) clients and three (3) staff present.

MEDICATION REVIEW: Medications review began at 1:20 PM. Medications were observed locked in the hallway cabinet. Medications for two (2) residents were observed. All medications are labeled and maintained in compliance with label instructions, and state and federal law. All medications reviewed were recorded on the centrally stored medication and destruction record. The LPA inspected the first aid kit, which was complete.

Continued on LIC 809-C

SUPERVISOR'S NAME: Kasandra Lopez	TELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Esther Cortez	TELEPHONE: (747) 230-2225
LICENSING EVALUATOR SIGNATURE:	DATE: 07/09/2024

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/09/2024

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)

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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS N.ASC, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: ROSE GARDEN MANOR IV	FACILITY NUMBER: 565802133
	VISIT DATE: 07/09/2024

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At 1:51 PM the LPA along with facility staff toured the physical plant areas inside and outside to ensure there are no health and safety hazards and facility is in compliance with Title 22 Regulations. The following was observed: The LPA observed two (2) fire extinguishers at the facility, which were fully charged and last serviced 10/16/2023. At 02:05 PM, all smoke alarms and carbon monoxide detectors were tested and functioned properly. The LPA observed all required postings in the common area.

KITCHEN: Kitchen appliances appeared to be in operable condition. The facility has a sufficient supply of perishable and non-perishable food, as well as emergency food and water supply. All knives and cleaning supplies were observed to be locked and properly stored at the time of the visit.

BEDROOMS: The LPA observed the resident bedrooms, which were furnished appropriately with clean linens, appropriate furnishings and sufficient lighting. There are four (4) total bedrooms; 2 (two) are designated for private resident use and 2 (two) are designated as shared resident rooms.

RESTROOMS: The LPA observed 2 (two) restrooms in the facility; one is a shared restroom and one is a private restroom. Resident restrooms are clean and sanitary and in operating condition with grab bars and non-skid surfaces. Water temperature was measured in the private resident restroom at 2:02PM and measured at 112.1 degrees Fahrenheit, which is within the required range.

COMMON SPACES/OUTDOOR SPACE: In the common areas, walls and flooring were checked for cleanliness and good condition. At the time of the visit, living room and dining room furniture was observed to be in good condition. A fireplace was observed to be adequately inaccessible. Laundry room was observed with locked chemical storage. The backyard has an enclosed patio and outdoor area equipped for resident use. There were no bodies of water noted. The detached garage was observed unlocked and contained storage.

INTERVIEWS: Throughout today's visit, LPA interviewed two (2) residents and two (2) staff. No immediate concerns were voiced.

Exit interview conducted. A copy of the report was provided.

SUPERVISOR'S NAME: Kasandra Lopez	TELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Esther Cortez	TELEPHONE: (747) 230-2225
LICENSING EVALUATOR SIGNATURE:	DATE: 07/09/2024

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/09/2024

LIC809 (FAS) - (06/04)

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